SUD Third Party Referral Form

Recovering Hope Referral Form

Substance Use Services
Requested Services

Check all that apply
Services

Women’s Residential Treatment (ASAM 3.5 – High Intensity)Women’s Residential Treatment (ASAM 3.5 – Medium Intensity)Residential Transportation for IntakeIntensive Outpatient Treatment (ASAM 2.1) + Board and LodgingIntensive Outpatient Treatment Only (ASAM 2.1)Outpatient Treatment (ASAM 1.0)
If the client does not have a comprehensive assessment

Please note: If the client is in need of Direct Access and no comprehensive assessment is available, our Admissions team will conduct a brief pre-screener over the phone. Once the client completes their intake, we will complete the comprehensive assessment first, then proceed with the rest of the admission process.

If the client is unsure of what level of care they need, you can encourage them to use our walk-in hours (Monday–Friday, 8:00 a.m. to 1:00 p.m.). In many cases, they may be able to start treatment that same day.

We’re here to help—don’t hesitate to reach out with questions or if you need support navigating the referral.
Referral Source
Referral Type

Probabtion OfficerCounty/Case WorkerCPS or ICWADetoxHospitalCare FacilityAnother Treatment FacilityOther
Referring Agency
Referant Name
Referent Phone Number
Referent Email
Relationship to Client
Client Information
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance and Funding
Does the client have healthcare coverage or secure funding?

YesNo
Has the client already applied for insurance?

YesNo
Please indicate the County of Financial Responsibility or the county the client last applied for healthcare coverage in:
Primary Funding Sources ( select all that apply )

Minnesota Medicaid (MA): Includes PMAP plans like BCBS, UCare, Medica, Health Partners, and Hennepin Health.MNcare: A state program that provides affordable health coverage to individuals and families with low income who don't qualify for Medicade.MedicareCommercial InsuranceSelf-PayBehavioral Health Fund ( OO span )Other
Insurance Provider Name
PMI Number
ID Number
Group Number
Bringing a Child to Residential
Is the client planning to bring their child with them, or reunify while in treatment?

YesNo
Name and Date of Birth of Child:
Is there CPS/ICWA involvement?

YesNo
If Yes, what is the CPS/ICWA workers name?
Bringing or Reunifying with a Child During Treatment

If a client plans to bring their child with them or is working toward reunification during treatment, our Admissions team will conduct a pre-screening to assess readiness and identify any potential barriers. This helps us ensure a safe and supportive environment for both the client and their child.

Depending on the client’s circumstances—whether they are currently parenting or planning to reunify later—we may request verification from third parties to confirm there are no legal or protective concerns that would prevent the child from residing with the client. This may include:
- Active child protection involvement
- Custody or divorce-related restrictions
- Legal orders limiting the client’s ability to care for or reside with their child
Once cleared, the client may be placed in a designated “Mom Room.” If a room is not immediately available, they may be added to a waitlist.

Please let our team know as early as possible if reunification or parenting during treatment is being considered so we can plan accordingly.
Legal System Involvement
Do any of these apply:

Being released from jailOn a furloughUnder full civil commitmentUnder partial civil commitmentUnder legal guardianshipOther
Scheduling/Planning
Expected Date of Engagment in Services

MonthDayYear
Date
Additional Notes or Relevant Information
Release of Information

If you are assisting the client with intake coordination—such as a case manager, probation officer, social worker, or other involved party—please submit a Release of Information (ROI) so we can coordinate care.
🔗 Upload a signed ROI (if available) below
🔗 Click here to complete our secure online ROI form
Clinical Documentation Upload
Please upload any of the following clinical documents to support intake, transfer, or coordination of care:

✅ Recent Comprehensive Substance Use Assessment
✅ Recent or active Weekly Treatment Plan
✅ Recent or final Discharge Summary
✅ Any other relevant transfer paperwork or case notes
📤 Add your File Upload Field here (set to allow multiple documents)
File Upload

Cancelof
Should be Empty:

Recovering Hope Referral Form

Requested Services

If the client does not have a comprehensive assessment

Referral Source

Client Information

Insurance and Funding

Bringing a Child to Residential

Bringing or Reunifying with a Child During Treatment

Legal System Involvement

Scheduling/Planning

Release of Information

Clinical Documentation Upload

Please upload any of the following clinical documents to support intake, transfer, or coordination of care: